Current smokers have twice the risk of cardiovascular mortality compared with never smokers. Former smokers have about a 37% increased risk of cardiovascular mortality compared to never smokers. The excess risk in smokers was positively correlated with number of cigarettes smoked per day. The excess risk in former smokers decreased continuously with time since smoking cessation. (BMJ. 2015 Apr 20;350:h1551.)

Sunday, April 19, 2015

A rapid strategy to evaluate patient with suspected acute myocardial infarction included a baseline high sensitivity cardiac troponin T level, a repeat level in 1 hour, and observation care for equivocal cases. Within 1 hour, 40% of patients were classified as ruled-in or ruled-out, and 60% went on to observation care. The sensitivity and negative predictive value in the ruled-out group was over 99%. 30-day mortality was 0% in the ruled out group. (CMAJ 2015. DOI:10.1503 /cmaj.141349)

Friday, February 13, 2015

Older patients presenting to an outpatient clinic with non-acute chest pain frequently have an underlying cardiac etiology. Once the decision is made to evaluate for CAD, how should the workup proceed? Here is one approach.
1. Referral to a cardiologist can be made simultaneously with initiation of the outpatient workup. Many but not all patients will need to see a cardiologist regardless of test results. It can significantly decrease time to diagnosis if workup is initiated at the same time as the referral.

2. Perform an EKG and standard blood tests.

3. Order a stress test. Type of stress test is primarily influenced by EKG findings, the pre-test probability, and patient's ability to adequately exercise.

4. EXERCISE TREADMILL: treadmill only testing is generally indicated for low risk patients who are able to adequately exercise and have an interpretable ECG.

5. STRESS IMAGING: stress SPECT imaging is generally recommended in patients with any of the following:

Why is stress SPECT the most commonly performed stress imaging study? One reason is because it is highly quantitative, making the results highly consistent from one lab to another. Advances in computer software have greatly decreased the subjectivity of scan interpretation. Scan interpretation is very consistent across a wide range of clinical settings.

Healthy eating and increased physical activity from walking are associated with a wide range of improved outcomes during pregnancy, during birth, and postpartum. One important benefit appears to be a reduced risk of pre-eclampsia in women who consume a diet high in fruits and vegetables. BMC Medicine 2014, 12:176

Monday, January 26, 2015

People with respiratory illnesses appear to greatly benefit from walking from 3 to 6 km a day. Walking this much a day appears to significantly reduce the risk of hospitalization for respiratory illnesses.

Sunday, January 25, 2015

As a young doctor, I felt it was time to speak out at a public forum on keeping our local hospital strong. So what did I do? I decided to quote from George Orwell's book, Animal Farm. Although this was a serious forum, that addressed important issues, bringing up a quote from Orwell was quite pleasing to me, probably because Orwell's book on animals was being played right in front of me, by people. The crux of the argument was this: should some doctors receive extra taxpayer money from our local hospital district, while the other doctors in private practice were left out? Although the long-term outcome of this issue resulted in the doctors who relied on subsidies all leaving town, the issue is much larger than one town hall meeting. It's about a philosophy of living.

As a child, I was raised in a relatively strict Catholic household. For example, my first piano teacher was a nun, and she held a ruler in her hand and struck me whenever I played a wrong note. We went to church every Sunday, said our prayers at every meal, and were taught to read the Bible. While these routines were important, the messages behind the religion were what counted, namely:

The strong must help the weak.

The healthy must help the sick.

Adults must teach their children

Adults must protect children.

The rich must help the poor.

"And to whomsoever much is given, of him shall much be required." -Luke 12:48

All of us have been given something of value, that others have in less abundant supply. But I was always told that I was very fortunate, that God had given me "much." Therefore, our religion and basic morality demanded that I serve others and give back as much as I could. And this was why that nun hit my fingers with a ruler--- I was given a gift from God, and darn it, I better cultivate that gift or else.

Which brings us back to the city forum, where some doctors where claiming that they deserved a public subsidy, but the other doctors in town did not. Their reasons were specious at best, but it made me think of two things. Shouldn't the strong help the weak? And shouldn't all of the doctors be treated equally? Well to make this point, George Orwell saved the day.

In Animal Farm, the pigs (think corrupt politicians) initially promoted the idea that "All animals are equal." As the story developed, the pigs eventually wanted more power. They wanted to live in the house, they wanted better food, they wanted more. But they were constrained by their initial saying that all animals are equal. So what did they do? By taking small, almost imperceptible steps, they changed the saying to "All animals are equal, but some are more equal than others." This is what was happening right in front of my eyes. Those who were given much, were focused on getting more. Those that were in positions of power were saying that they were more equal than others, and deserved special treatment.

What did I do? I spoke up and said in so many words that we should avoid imitating the pigs in Animal Farm. We should consider everyone in our community as equals, and make it our public morality to help the weak, the poor, and the disadvantaged. Although my argument did not carry the day right then, ultimately all of those who were asking for special privileges left town looking for greener pastures, and those of us keeping our heads down and focusing on our work stayed. I'd like to think we proved through our actions that our community was made up of equals, and that in some way, all of us had strengths we could share with others. All of us had weaknesses that could benefit from the help of others. We rejected the Animal Farm pig philosophy.

Looking back, here's what I learned.

Reading the classics, like Animal Farm, can have a lasting and important impact on our lives. Classic books are classic for a good reason.

Moral principles may be challenged in the short run, but they will prevail in the long run.

Quoting from classical literature (including the Bible) can help focus our thoughts, and see things more clearly and more deeply.

Mom and Dad were right.

Here's a partial list of some of my favorite fictional works of literature I've read over the years. What are yours?

The authors of the research into wisdom found that wisdom was associated with:

personal growth

life satisfaction with self and others

a concern for the welfare of others

But after reading this article, I had a nagging question: are these associations side-effects from the development of wisdom, or factors that help develop wisdom? What came first? Wisdom, or the above factors? My own view is that we start with a strong curiosity and desire to learn. Then we ponder and meditate on our learning. Finally, we must take action and gauge the results.

One of the big lessons I've learned over the years is that humility is a fundamental feature of personal growth. There is so much to learn from others, and this learning can come at the most unexpected times, from the most unexpected people.

I had a friend on the Wardner City Council that would constantly refer to "educated idiots." What he was referring to were people from other communities who would come to our town and think they knew it all. They had a good education, but they didn't understand the local environment. They were educated, but when it came to understanding Wardner, they were idiots. Thus the term, educated idiots. The lesson? Be humble with others.

Applied to my medical practice, this means that when I evaluate a new patient, I always do my best to understand their point of view. What do they think is happening? What are they afraid of? What would they like done? What does the family think is going on?

I also try my best to keep an open dialogue with my co-workers, including nurses, physical therapists, and pharmacists to name a few. What do they think is going on with the patient?

This listening to others doesn't mean I disregard my own thoughts or my own education. Listening simply indicates an openness to learning more and the possibility that my own initial impression may be wrong. By really listening to others, and most especially to our patients, we are lifelong learners.